Equine Health Certificate
Owner's name *
Your answer
Date of Travel *
MM
/
DD
/
YYYY
Owner's Address Street City State zip *
Your answer
Owner's cell phone *
Your answer
Owner's email *
Your answer
Is Address of Origin same as owner's address ? *
If not, Address of Origin (street, city, state, zip)
Your answer
Is Consignee same as owner (person accepting horse at destination address)? *
Consignee Name (if different than owner)
Your answer
Consignee Address (street, city, state, zip)
Your answer
Destination Address (street, city, state, zip) *
Your answer
Is Carrier same as owner *
If not, Carrier Name
Your answer
Carrier Address (Street, city, state, zip)
Your answer
Carrier phone number
Your answer
Horse's name *
Your answer
Age *
Your answer
Height *
Your answer
Color *
Your answer
Breed *
Your answer
Sex *
Brand and/or Tatoo ?
Your answer
Microchip Number
Your answer
Do you have a current coggins ? *
Lab name *
Your answer
Accession number *
Your answer
Date of Negative Result *
MM
/
DD
/
YYYY
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This form was created inside of 5 Elements for Animals.